A 55-year-old patient with POAG has progressive field loss despite IOP of 16 mmHg on maximal tolerated medical therapy. The next most appropriate step, per current guidelines, is:

• A Selective laser trabeculoplasty (SLT) as an add-on therapy
• B Drainage implant (tube shunt) surgery
• C Cyclophotocoagulation
• D Trabeculectomy with mitomycin C ✓

Explanation

When maximal medical therapy fails to halt progressive visual field loss, surgical intervention is indicated. Trabeculectomy with mitomycin C remains the gold standard filtration surgery for medically uncontrolled glaucoma, providing the greatest IOP reduction. Tube shunts (TVT study) are preferred when trabeculectomy is likely to fail (e.g., prior failed trabeculectomy, scarred conjunctiva). SLT is an adjunct, not first-line surgery. Cyclophotocoagulation is reserved for refractory end-stage glaucoma.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.